Methods of treating cancer in subjects having dysregulated lymphatic systems

ABSTRACT

Provided herein is a method for treating cancer in a patient in need thereof, wherein said cancer has a tumor proportion score (TPS) for programmed death receptor-1 (PD-11) or programmed death-ligand-1 (PD-L1) of 50% or less and said patient is negative for lymphatic dysfunction, comprising administering a therapeutically effective amount of an antagonist for immune checkpoint inhibition.

This application claims the benefit of the filing date of U.S.Provisional Application No. 62/649,048, filed Mar. 28, 2018, which isincorporated by reference in its entirety for all purposes.

This disclosure relates to the field of treating cancer, particularlycancer in subjects having dysregulated lymphatic systems to whom animmune modulating therapy is applied.

Patients who suffer from a dysregulated lymphatic system do not respondto immune modulating therapies, which depend on immune cell priming,antigen presentation or antigen trafficking. Patients with tumorstreated with cancer immune modulating therapy do not respond. By notresponding, patients specifically rapidly progress from their tumor withminimal to no response period. Similarly, such patients have extremelypoor overall survival compared to their counterparts who do not havedysregulation, or dysfunction of their lymphatic system. Also, patientswith lymphangitic carcinomatosis or lymphatic invasion do not respond tosuch cancer immune modulating therapies, for a lack of immune cellactivation and immune cell priming.

As a broad class, immune modulating therapies have remarkably benefitedcancer patients in small and select groups. PD-1 and PD-L1 and relatedimmune checkpoint inhibitors have remarkable response profiles in lessthan 30% of patients. Most studies positively correlate PD-1/PD-L1staining in cancer patients and response, whether overall survival (OS),progression free survival (PFS), objective response rate (ORR) ordurable clinical response (DCR), irrespective of the pharmaceutical used(e.g. durvalumab, avelumab, nivolumab, atezolizumab, and pembrolizumab).The current art teaches that patients with certain tumor typesconsistently do not respond well, with less than 20% having any responseto these therapies. These cancers include non-small cell lung cancer(NSCLC), prostate cancer, breast cancers such as triple negative,estrogen receptor positive, and inflammatory types, nonhypermutatedtumors, such as mismatch repair deficient (MMRD) tumors, microsatellite(MSI) instability positive or negative cancers, glioblastoma multiforme,and colon cancers.

The foregoing examples of the related art and limitations relatedtherewith are intended to be illustrative and not exclusive. Otherlimitations of the related art will become apparent to those of skill inthe art upon a reading of the specification and a study of the drawings.

The following embodiments and aspects thereof are described andillustrated in conjunction with compositions and methods, which aremeant to be exemplary and illustrative, not limiting in scope. Invarious embodiments, one or more of the above-described problems havebeen reduced or eliminated, while other embodiments are directed toother improvements.

Provided herein is a method for treating cancer in a patient in needthereof, wherein said cancer has a tumor proportion score (TPS) forprogrammed death receptor-1 (PD-1) or programmed death-ligand-1 (PD-L1)of 50% or less and said patient is negative for lymphatic dysfunction,comprising administering a therapeutically effective amount of anantagonist for immune checkpoint inhibition.

In certain embodiments, the TPS is 30% or less, such as the TPS being10% or less.

In certain embodiments, the lymphatic dysfunction is lymphangiticcarcinomatosis (LC).

In certain embodiments, the immune checkpoint inhibition has a targetchosen from PD-1, PD-L1, CTLA-4, LAG3, TIM-2, CD47, KIR, TIM3, CD30,OX40, IDO, and ICOS.

In certain embodiments, the immune checkpoint inhibition targets PD-1 orPD-L1.

In certain embodiments, the antagonist is chosen from afatinibdimaleate, alectinib, bevacizumab, carboplatin, ceritinib, crizotinib,docetaxel, doxorubicin, erlotinib, etoposide, everolimus, gefitinib,gemcitabine, mechlorethamine, methotrexate, necitumumab, nivolumab,osimertinib, paclitaxel, paclitaxel albumin-stabilized nanoparticles,pembrolizumab, pemetrexed, ramucirumab, topotecan, vinorelbine,pharmaceutically acceptable salts thereof, and combinations thereof.

In certain embodiments, the antagonist is chosen from bevacizumab,necitumumab, nivolumab, pembrolizumab, ramucirumab, pharmaceuticallyacceptable salts thereof, and combinations thereof.

In certain embodiments, the antagonist is pembrolizumab orpharmaceutically acceptable salts thereof.

In certain embodiments, the cancer is chosen from lung cancer, breastcancer, a cancer of the gastrointestinal tract, a cancer of unknownorigin, head and neck cancer, bladder cancer, prostate cancer, skincancer, kidney cancer, a primary brain tumor, ocular tumor, sarcoma, acancer of primary soft tissue, mesenchymal cancer, bone cancer, ovariancancer, cervical cancer, a tumor of the lymphatic system, leukemia,mismatch repair deficient positive tumors (MMRD positive), and mismatchrepair deficient negative tumors (MMRD negative), and microsatellite(MSI) instability positive or negative cancers.

In certain embodiments, the cancer is lung cancer chosen from non-smallcell lung cancer (NSCLC), squamous cell lung cancer, large cell lungcancer, small cell lung cancer, bronchogenic carcinoma, adenocarcinoma,neuroendocrine lung cancer, and bronchoalveolar lung cancer.

In certain embodiments, the cancer is breast cancer chosen from ductalcarcinoma in situ (DCIS), invasive ductal carcinoma (IDC), lobularcarcinoma (ILC), inflammatory breast cancer, lobular carcinoma in situ(LCIS), male breast cancer, Paget's disease of the nipple, and Phyllodestumors of the breast.

In certain embodiments, the breast cancer is invasive ductal carcinomachosen from tubular carcinoma of the breast, medullary carcinoma of thebreast, mucinous carcinoma of the breast, papillary carcinoma of thebreast, and cribriform carcinoma of the breast.

In certain embodiments, the cancer is breast cancer defined by hormonereceptor status chosen from estrogen receptor positive, estrogenreceptor negative, progesterone receptor positive, progesterone receptornegative, herceptin positive, herceptin negative, and combinationsthereof.

In certain embodiments, the cancer is breast cancer defined byexpression of a predefined set of genes chosen from mammaprint,oncotypeDX, intrinsic subtypes, and nanostring prosigna.

In certain embodiments, the cancer is a cancer of the gastrointestinaltract chosen from a tumor of the stomach, gastric cancer, duodenalcancer, small or large intestine cancer, colorectal cancer, anal cancer,liver cancer, pancreatic cancer, gall bladder cancer,cholangiocarcinoma, and neuroendocrine cancer.

In certain embodiments, the cancer is a skin cancer chosen from basalcell cancer, squamous cell cancer, and melanoma.

In certain embodiments, the cancer is kidney cancer chosen from renalcell cancer and oncocytoma.

In certain embodiments, the cancer is a primary brain tumor, chosen fromglioma, a tumor with gliomatous components, a tumor with neuronalcomponents, a tumor with oligodendroglial components, oligodendroglioma,astrocytoma, and glioblastoma multiforme.

In certain embodiments, the cancer is a tumor of the lymphatic systemselected form the group consisting of B cell lymphoma, T cell lymphoma,diffuse B cell lymphoma, and Hodgkin's lymphoma.

In certain embodiments, the cancer is leukemia chosen from acutelymphoblastic leukemia, acute myeloid leukemia, chronic lymphocyticleukemia, and chronic myelogenous leukemia.

In certain embodiments, the cancer is lung cancer and the antagonist ischosen from afatinib dimaleate, alectinib, bevacizumab, carboplatin,ceritinib, crizotinib, docetaxel, doxorubicin, erlotinib, etoposide,everolimus, gefitinib, gemcitabine, mechlorethamine, methotrexate,necitumumab, nivolumab, osimertinib, paclitaxel, paclitaxelalbumin-stabilized nanoparticles, pembrolizumab, pemetrexed,ramucirumab, topotecan, vinorelbine, pharmaceutically acceptable saltsthereof, and combinations thereof.

In certain embodiments, the cancer is advanced cancer or metastaticcancer.

Also provided is a method for treating lung cancer in a patient in needthereof, which cancer has a tumor proportion score for programmed deathreceptor-1 (PD-1) or programmed death-ligand-1 (PD-L1) of 30% or lessand said patient is negative for lymphangitic carcinomatosis (LC),comprising administering a therapeutically effective amount of anantagonist for immune checkpoint inhibition targeting PD-1 or PD-L1.

Further provided for treating lung cancer in a patient in need thereof,which cancer has a tumor proportion score for programmed deathreceptor-1 (PD-1) or programmed death-ligand-1 (PD-L1) of 30% or lessand said patient is negative for lymphangitic carcinomatosis (LC),comprising administering a therapeutically effective amount ofpembrolizumab or a pharmaceutically acceptable salt thereof.

The disclosure also provides a method for treating cancer in a patientin need thereof, by determining if said cancer has a tumor proportionscore for programmed death receptor-1 (PD-1) or programmeddeath-ligand-1 (PD-L1) of 30% or less and confirming said patient isnegative for lymphatic dysfunction, then administering a therapeuticallyeffective amount of an antagonist for immune checkpoint inhibition.

The disclosure further provides a for treating cancer in a patient inneed thereof, wherein said cancer has a tumor proportion score forprogrammed death receptor-1 (PD-1) or programmed death-ligand-1 (PD-L1)of 30% or less by administering a therapeutically effective amount of anantagonist for immune checkpoint inhibition.

Additional embodiments and features are in part in the description thatfollows, and in part will become apparent to those skilled in the artupon examination of the specification, or may be learned by the practiceof the embodiments discussed herein. A further understanding of thenature and advantages of certain embodiments may be realized byreference to the remaining portions of the specification and thedrawings, which forms a part of this disclosure.

BRIEF DESCRIPTION OF THE DRAWINGS

The disclosure will be readily understood by the following detaileddescription in conjunction with the accompanying drawings, wherein likereference numerals designate like structural elements. The drawingsprovide exemplary embodiments or aspects of the disclosure and do notlimit the scope of the disclosure.

FIG. 1 is a schematic of general lymphatic biology showing moleculesthat modulate tumor lymphangiogenesis. See Stacker et al.,“Lymphangiogenesis and lymphatic vessel remodeling in cancer,” NatureReviews Cancer, 14:159-172 (2014), incorporated herein by reference.

FIG. 2 is a schematic showing The VEGF family of ligands and theirrespective binding patterns to the VEGFR. See Karkkainen et al.,“Lymphatic endothelium: a new frontier of metastasis research,” NatureCell Biology, 4:E2-E5 (2002).

FIG. 3 is a flow chart showing the percentage of patients that arePD-L1+ and PD-L1-based on tumor proportion score (TPS>50%, TPS 1-49%,TPS<1%) in NSCLC.

FIG. 4 is the FDA drug label for the PD-1 checkpoint inhibitorpembrolizumab superficially teaches the use of pembrolizumab in NSCLCpatients only in patients with a TPS>=1%.

FIG. 5 is a pie chart showing the proportion of NSCLC tumors that areLC+ and LC−.

FIG. 6 is a pie chart showing the percentage of NSCLC patients that areLC+/PD-L1− (20% blue)— and LC−/PD-L1− (80% orange). Thus, while it hasbeen shown that only that those patients with very high TPS scores (>50%PD-L1 staining) will receive clinical benefit, and that patients withlow TPS or negative (PD-L1 1-49% or (<1—approximately 30% of allpatients have a TPS<1%)) do not derive benefit, this chart shows that ofTPS<1%, only 20% are LC+(TPS<1%/LC+), while the remaining 80% areLC−(TPS<1%/LC−). Thus, of the 30% not offered therapy because ofpresumed lack of benefit due to low TPS score (TPS<1%), 80% of thesepatients derive a real clinical benefit when stratified by LC statusalone, which is a much stronger predictor of response independent of TPS(FIGS. 7-9).

FIG. 7 is a Kaplan Meier plot showing a set of NSCLC patients treatedwith the PD-1 checkpoint inhibitor pembrolizumab (Keytruda™) stratifiedby LC+(biomarker positive “1” group OS=67 days) versus LC− (Biomarkernegative “0” group OS=347 days). Patients that respond are defined by LCstatus independent of PD-L1 status (Cox proportional hazards analysisP<0.05).

FIG. 8 shows overall survival (% alive) as a function of time in days.Biomarker positive patients survived a median of 47 to 67 days.Biomarker negative patients survived a median of 445 days.

FIG. 9 shows progression free survival (%) as a function of time indays. Biomarker positive patients had a median survival of 47 to 68days. Biomarker negative patients had a median survival of 189 days.

DETAILED DESCRIPTION

I. Methods for Treating Cancer

Provided method for treating cancer in a patient in need thereof,wherein said cancer has a tumor proportion score (TPS) for programmeddeath receptor-1 (PD-1) or programmed death-ligand-1 (PD-L1) of 50% orless and said patient is negative for lymphatic dysfunction. The methodcomprises administering a therapeutically effective amount of anantagonist for immune checkpoint inhibition.

Molecules that modulate tumor lymphangiogenesis are shown at FIG. 1,with soluble ligands presented outside the cell, cognate receptors atthe cell surface and transcription factors in the nucleus. Vascularendothelial growth factor C (VEGFC) and VEGFD refer to theproteolytically processed, biologically active forms of these proteins.Most ligands shown promote lymphangiogenesis, while transforming growthfactor-β (TGFβ) inhibits lymphangiogenesis. Other molecules are known toparticipate in lymphatic development in the embryo, such as collagen andcalcium binding EGF domain-containing protein 1 (CCBE1; not shown), forwhich a role in tumor lymphangiogenesis has not been shown. Theinteraction of tumor cells with lymphatic vessels can be promoted byinterstitial fluid flow (which partly results from lymphatic drainage)via autologous chemotaxis involving chemokines, such as CC-chemokineligand 21 (CCL21), and their receptors (CCR7 in the case of CCL21),expressed by tumor cells. Expression of CCL21 on lymphatic endothelialcells (LECs) can promote the entry of tumor cells into lymphatics via aCCR7-dependent mechanism. Producing lymphangiogenic growth factors, suchas VEGFC and VEGFD, can drive the formation of new lymphatics andlymphatic enlargement near a tumor, which increases the surface area forthe interaction of tumor cells with lymphatics. VEGFC can also promotetumor cell invasiveness in an autocrine manner, and it can upregulatethe production of CCL21 on lymphatic vessels. The other abbreviationslisted are 15-PGDH, 15-hydroxyprostaglandin dehydrogenase; ANGPT2,angiopoietin 2; COUPTF2, COUP transcription factor 2; COX2,cyclooxygenase 2; CSF1, colony-stimulating factor 1; EGF, epidermalgrowth factor; EGFR, EGF receptor; EPO, erythropoietin; EPOR, EPOreceptor; FGF, fibroblast growth factor; FGFR, FGF receptor; FOXC2,forkhead box protein C2; PDGF-BB, platelet-derived growth factor BB;PDGFR, PDGF receptor; PROX1, prospero homeobox protein 1; RAMP2,receptor activity-modifying protein 2; SIP, sphingosine-1-phosphate;TGFβR, TGFβ receptor; VEGFR, VEGF receptor.

The VEGF family of ligands and their respective binding patterns to theVEGFRs are shown at FIG. 2. VEGFR-1 and neuropilin-1 (NRP-1) areexpressed in blood vascular ECs, VEGFR-3 and NRP-2 in lymphatic ECs, andVEGFR-2 occurs in both cell lineages. VEGFR-2 is the main signaltransducing receptor, as it activates several downstream signalingmolecules (circles), and induces responses such as cell proliferation,migration and survival. The protein kinase C (PKC)-mediated MEK/ERKpathway produces proliferation signals, in contrast to activating thePI3-kinase/Akt pathway, which regulates cell survival. Focal adhesionkinase (FAK) and PI3-kinase migrate cells by stimulating thereorganization of actin and recruitment of actin-anchoring proteins tothe focal adhesions. VEGF-C and VEGF-D are ligands for VEGFR-3, and theycan induce LEC survival, migration and growth via activation of theMEK/ERK and PI3-kinase/Akt pathways. However, after proteolyticcleavage, VEGF-C and VEGF-D can also bind and activate VEGFR-2 andstimulate both BECs and LECs. The distinct but overlapping receptorspecificities and receptor expression patterns determine how VEGFs candifferentially target both the blood vascular and/or lymphaticendothelium.

The art teaches that a patient's response to immune therapy depends onthe PD-1 or PD-L1 expression or tumor neoantigen status. For examples,hypermutant, microsatellite instability-high, DNA mismatch repairdeficient (dMMR), or high neoantigen burden phenotype tumors respondstrongly to checkpoint immune therapies. The cancers which are low in ordo not express PD-1 or PD-L1, or are not hypermutant, not dMMR,microsatellite instability-low or normal, or have low neoantigenburdens, do not respond to checkpoint immune therapy. Breast cancer,particularly triple negative (HER2−, ER−, PR−), ER+/HER2 negative, andinflammatory breast cancers, microsatellite instability low or normal,nonhypermutant/DNA mismatch repair low or normal colorectal cancers, andglioblastomas multiforme (GBMs), pancreatic cancer, sarcomas, andprostate cancers do not respond well to immune-modulating therapies. Tothe contrary, the present disclosure shows that the tumor typesdescribed above respond to immune checkpoint inhibition when treated inrelation to lymphatic dysfunction, independent of PD-1/PD-L1,microsatellite instability degree, dMMR status, orneoantigen/hypermutant tumor status or type.

The art also suggests that tumors with elevated levels oflymphangiogenesis should have a better prognosis and better response toimmune therapies because they have higher tumor immune cell infiltrates.To the contrary, following the present disclosure, such tumors should betreated with both immune modulation therapies, including immunecheckpoint inhibitors, and a modulator of lymphatic biology, such as aVEGR-3 inhibitor, VEGF-C, VEGF-D, NRP 1, NRP 2, or CCPE1.

As such, therapies that modulate (stimulate or inhibit) immune biologyat or downstream of this step are not effective monotherapies. They mustbe replaced with alternate therapies not dependent on these steps ormechanisms and treated with alternate therapies or these immunemodulating therapies will either need to be independent of immune cellpriming, antigen priming, or presentation or the immune modulatingtherapies dependent on these steps will need to be augmented or changedby agents that help to limit or overcome these issues. Further, cancerpatients treated with immune modulating therapies dependent on immunecell priming, antigen trafficking or antigen presentation (e.g. immunecheckpoint therapies) or patients that have dysregulated, dysfunctionalor perturbed lymphatic systems can as a class all be augmented and theirclinical profiles improved through augmentation with such agents(antibody or antibody derivatives, or small molecular or small moleculederativites) that regulate lymphatic angiogenesis.

Further, based on evaluation of the status of the lymphatic system inthe cancer subject, the potential treatment with an immune-modulatingtherapy is assessed. If subjects are determined to have dysregulation oftheir lymphatic system by having abnormal lymphatic system features,then the treatment with any immune-modulating therapy that depends onefficient immune cell priming or antigen presentation is either aborted,deferred, or is augmented by a treatment method that modulates thelymphatic system to overcome or offset the dysfunctions.

Targeting lymphatics surrounding cancer therapy exclusively focuses onlymphatics as conduits for metastasis and as a means of limitingmetastasis by preventing cancer cell spread along these conduits. Theprior art focuses on these therapies in the context of providing moresupport around tumor associated blood vessel angiogenesis by coveringthe vascular angiogenesis pathway that existing and marketed do notcover. The art does not teach specific and highly selective inhibitorsof lymphangiogenesis for augmenting or aiding immune modulation orimmune therapies. The prior art also does not teach aiding immunecheckpoint inhibitors as a principal means of augmenting the effects ofthese therapies, supporting or boosting immune therapies. Additionally,the prior art does not teach lymphangiogenesis inhibitors in combinationwith immune modulating therapies in patients with lymphaticdysregulation, dysfunction, or perturbation.

The prior art does not teach treating patients with dysfunctional,dysregulated or perturbed lymphatic systems as characterized bylymphatic invasion and or lymphangitic carcinomatosis. While the priorart suggested anti-lymphangiogenic agents in ongoing clinical trials,the agents were selected solely for their known role as primary cancertherapies that target and inhibit vascular angiogenesis and do notselectively inhibit lymphangiogenesis. They are nonspecific agents withhigh general specificity for the entire VEGF family of receptors andmany other angiogenesis related targets (e.g. PDGF-BB, HGF, etc.), notspecific and selective agents for VEGF-C/D and VEGFR 3. Additionally,the prior art does not teach lymphatic biology specific mediators as fortreating dysregulated lymphatics in the singular role of cancerimmunotherapy for targeting lymphatic dysregulation so that immunetherapies can more effectively function.

In a clinical setting, a major challenge is treatment of establishedmetastatic disease after the primary tumor has been surgically removed,eradicated by other means, or is unresectable. Following the presentdisclosure, established metastatic disease by blocking lymphangiogenesisusing antagonists of VEGF-C receptors, VEGFR-3 and VEGFR-2 incombination with cancer immune modulating therapies which can includebut are not limited to immune checkpoint inhibitors and in the settingof a dysregulated lymphatic system, or tumor associated lymphaticinvasion, lymphangitic carcinomatosis, or impaired antigen presentation,immune cell activation or priming alone or due to an impaired ordysregulated, dysfunctional or perturbed lymphatic system.

A. Lymphatic System

The lymphatic system comprises capillaries and larger collecting vesselscontinuously lined by endothelial cells which return extravasated fluidand macromolecules from the interstitial space back to the bloodcirculation. Thus, the lymphatic system plays a vital role in theregulation of fluid, protein, and pressure equilibrium in tissues. Bydirecting leukocytes and antigens from tissues to the lymph nodes,lymphatic vessels also have a key function in immune surveillance.Dysfunction of the lymphatic system results in lymphedema, a chronic anddisabling condition for which there are no treatments now available.Breast cancer treatment is associated with lymphedema, which oftendevelops following surgical removal of lymph nodes and radiationtherapy.

The lung is a common site for metastasis of many tumors, includingcommon tumors such as breast, colorectal, prostate, bronchial,head-and-neck, and renal cancers. Pulmonary nodules are the most commonmanifestation of metastatic cancer in the lungs. Without wishing to bebound by theory, they are thought to be derived from tumor emboli whicharrest in the lung capillaries and invade into the surrounding lungtissue. Involvement of pulmonary lymphatic vessels with cancer is lessdiagnosed because of the imaging difficulties. At necropsy, metastasesvia pulmonary lymphatics and bronchial arteries are often seen.

Lymphatic dysfunction (LD) is a process maintained, supported, orregulated, by the lymphatics inherently or acquire dysfunctionality, ordysregulation, including but not limited to processes involved inlymphangiogenesis, homeostatic regulation of the lymphatics vessels orsecondary or tertiary lymphoid structures, lymphatic remodeling,lymphatic flow, transit or transfer of materials within or through thelymphatics, antigens or cells within, through or across lymphaticconduits, the maintenance, support or transformation ofmicroenvironments including but not limited to the tumormicroenvironment, and the secretion or expression of factors that induceor modulate cellular recruitment, migration or trafficking such aschemokines, cytokines and other signaling molecules.

Involving lung lymphatics with cancer is a hallmark of a very aggressivemetastatic disease, designated “lymphangitic carcinomatosis.” LC is atype of LD in which obstruction of lymphatics to the primary orsecondary draining nodes or other lymphatic structures or conduitseither due to an extrinsic compression force or due to intrinsicinvasion of the lymphatics with cells, often abnormal cell, or tumorcells, or due to hypertrophy or growth of lymphatic supporting tissue,cells or the lymphatic endothelium. The prognosis for a patient withthis clinical picture is extremely poor; 50% of the patients die within3 months of diagnosis. Although lymphangitic spread can be caused by anymalignant cancer, it most commonly results from tumors originating inthe breast, stomach, pancreas, lung, or prostate. This phenomenon isalso caused by primary pulmonary carcinoma, especially small cellcarcinoma and adenocarcinoma. Because of the extremely aggressive natureof this disease, there is a great need for early diagnosis andtreatment. Before the present disclosure, no treatment improved outcomeof patients with lymphangitic carcinomatosis.

Lymphangitic carcinomatosis is an aggressive disease that has been seenin association with many common metastatic cancers such as breast,gastric, pancreatic, prostate cancer and others. Primary lung cancer canalso present in the form of lymphangitic carcinomatosis, suggesting thattargeting of VEGF-C/VEGFR-3 in lung cancer could be a treatment optionfor slowing the progression of lung cancer in combination with cancerimmune modulating therapies which can include, but are not limited, toimmune checkpoint inhibitors and in the setting of a dysregulatedlymphatic system, or tumor associated lymphatic invasion, lymphangiticcarcinomatosis, or impaired antigen presentation, immune cell activationor priming alone or due to an impaired or dysregulated, dysfunctional orperturbed lymphatic system.

Clinically, lymphangitic carcinomatosis is characterized by the presenceof malignant cells in the lymphatic vessels localized in theperi-bronchovascular area, in the interlobular septa, and in thecentrilobular region. Associated pleural involvement is common. Edema,resulting from blockage of lymphatic drainage and a desmoplasticreaction, are common and can contribute to interstitial thickening.Hilar and mediastinal lymphadenopathy are present in 20-40% of patients,and pleural effusions are present in 30-50% of patients.

The lymphatic system may be assessed through imaging. The imaging maycomprise one or more chosen from computer-assisted tomography (CAT),magnetic resonance imaging (MRI), positron emission tomography (PET),lymphoscintigraphy, and radiography of radiolabeled agents. The imagingmay be computer-assisted tomography (CAT). The imaging may be magneticresonance imaging (MRI). The imaging may be positron emission tomography(PET). The imaging may be lymphoscintigraphy. The imaging may beradiography of radiolabeled agents.

The lymphatic system may be assessed by measuring levels in a tissuesample of one of more first factors chosen from D2-40, podoplanin, CD34,and LYVE-1.

The first factor may be D2-40, a monoclonal antibody to an MW 40,000O-linked sialoglycoprotein that reacts with a fixation-resistant epitopeon lymphatic endothelium.

The first factor may be podoplanin.

The first factor may be CD34. Hematopoietic progenitor cell antigen CD34also known as CD34 antigen is a protein that in humans is encoded by theCD34 gene. CD34 is a cluster of differentiation in a cell surfaceglycoprotein and functions as a cell-cell adhesion factor. CD34 may alsomediate the attachment of stem cells to bone marrow extracellular matrixor directly to stromal cells.

The first factor may be LYVE-1. Lymphatic vessel endothelial hyaluronanreceptor 1 (LYVE1), also known as extracellular link domain containing 1(XLKD1) is a Link domain-containing hyaladherin, a protein capable ofbinding to hyaluronic acid (HA), homologous to CD44, the main HAreceptor. In humans, it is encoded by the LYVE1 gene.

The tissue sample may be concurrently stained for one or more secondfactors chosen from angiopoietin-1, angiopoietin-2, BMP-9, EGF,endoglin, endothelin-1, FGF-1, FGF-2, follistatin, G-CSF, HB-EGF, HGF,IGF, IL-8, leptin, MMP-2, MMP-9, NRP 1, NRP 2, PDGF, PIGF, PLGF, TIE1/2,VEGF-A, VEGF-C, and VEGF-D to determine levels of these factors withinlymphatics.

The second factor may be angiopoietin-1. The second factor may beangiopoietin-2.

The second factor may be BMP-9, also known as GDF2, contains anN-terminal TGF-beta-like pro-peptide (prodomain) (residues 56-257) and aC-terminal transforming growth factor beta superfamily domain (325-428).GDF2 (BMP9) is secreted as a pro-complex consisting of the BMP9 growthfactor dimer non-covalently bound to two BMP9 prodomain molecules in anopen-armed conformation.

The second factor may be epidermal growth factor (EGF), which stimulatescell growth and differentiation by binding to its receptor, EGFR. HumanEGF is a 6-kDa protein with 53 amino acid residues and threeintramolecular disulfide bonds.

The second factor may be endoglin (ENG), which is a type I membraneglycoprotein on cell surfaces and is part of the TGF beta receptorcomplex. Endoglin is also commonly referred to as CD105, END, FLJ41744,HHT1, ORW and ORW1. Endoglin has a crucial role in angiogenesis,therefore, making it an important protein for tumor growth, survival andmetastasis of cancer cells to other locations in the body.

The second factor may be endothelin-1 (ET-1), also known aspreproendothelin-1 (PPET1), is a potent vasoconstrictor that in humansis encoded by the EDN1 gene and produced by vascular endothelial cells.The protein encoded by this gene is proteolytically processed to releasea secreted peptide termed endothelin 1. Endothelin 1 is one of threeisoforms of human endothelin.

The second factor may be heparin-binding growth factor 1 (FGF-1) is aprotein that in humans is encoded by the FGF1 gene.

The second factor may be heparin-binding growth factor 2 (FGF-2) is aprotein that in humans is encoded by the FGF2 gene. FGF-1.

The second factor may be follistatin, also known as “activin-bindingprotein.” Follistatin is a protein that in humans is encoded by the FSTgene. Follistatin is an autocrine glycoprotein expressed in all tissuesof higher animals.

The second factor may be granulocyte-colony stimulating factor (G-CSF orGCSF), also known as colony-stimulating factor 3 (CSF 3). G-CSF is aglycoprotein that stimulates the bone marrow to produce granulocytes andstem cells and release them into the bloodstream. Functionally, it is acytokine and hormone, a type of colony-stimulating factor, and isproduced by many different tissues. The pharmaceutical analogs ofnaturally occurring G-CSF are called filgrastim and lenograstim. G-CSFalso stimulates the survival, proliferation, differentiation, andfunction of neutrophil precursors and mature neutrophils.

The second factor may be heparin-binding EGF-like growth factor(HB-EGF), which is a member of the EGF family of proteins that in humansis encoded by the HBEGF gene. HB-EGF-like growth factor is synthesizedas a membrane-anchored mitogenic and chemotactic glycoprotein. Anepidermal growth factor produced by monocytes and macrophages, due to anaffinity for heparin is termed HB-EGF. It plays a role in wound healing,cardiac hypertrophy, and heart development and function. HB-EGF is an87-amino acid glycoprotein that displays highly regulated geneexpression. Ectodomain shedding results in the soluble mature form ofHB-EGF, which influences the mitogenicity and chemotactic factors forsmooth muscle cells and fibroblasts. The transmembrane form of HB-EGF isthe unique receptor for diphtheria toxin and functions in juxtracrinesignaling in cells. Both forms of HB-EGF participate in normalphysiological processes and in pathological processes including tumorprogression and metastasis, organ hyperplasia, and atheroscleroticdisease. HB-EGF can bind two locations on cell surfaces: heparan sulfateproteoglycans and EGF-receptor effecting cell to cell interactions.

The second factor may be hepatocyte growth factor (HGF) or scatterfactor (SF). HGF is a paracrine cellular growth, motility andmorphogenic factor. HGF is secreted by mesenchymal cells and targets andacts primarily upon epithelial cells and endothelial cells, but alsoacts on haemopoietic progenitor cells and T cells. It has a key role inembryonic organ development, specifically in myogenesis, in adult organregeneration, and in wound healing.

The second factor may be insulin-like growth factor 1 (IGF-1), alsocalled somatomedin C. IFG-1 is a protein that in humans is encoded bythe IGF1 gene. IGF-1 has also been referred to as a “sulfation factor”and its effects were termed “nonsuppressible insulin-like activity”(NSILA).

The second factor may be interleukin 8 (IL-8 or chemokine (C-X-C motif)ligand 8, CXCL8) is a chemokine produced by macrophages and other celltypes such as epithelial cells, airway smooth muscle cells andendothelial cells. Endothelial cells store IL-8 in their storagevesicles, the Weibel-Palade bodies. In humans, the interleukin-8 proteinis encoded by the CXCL8 gene. IL-8 is initially produced as a precursorpeptide of 99 amino acids which then undergoes cleavage to createseveral active IL-8 isoforms. In culture, a 72-amino acid peptide is themajor form secreted by macrophages.

The second factor may be leptin. Leptin the “satiety hormone”, is ahormone made by adipose cells that helps to regulate energy balance byinhibiting hunger. Leptin is opposed by the actions of the hormoneghrelin, the “hunger hormone”. Both hormones act on receptors in thearcuate nucleus of the hypothalamus to regulate appetite to achieveenergy homeostasis. In obesity, a decreased sensitivity to leptinoccurs, resulting in an inability to detect satiety despite high energystores.

The second factor may be matrix metalloproteinase 2 (MMP-2). Also knownas 72 kDa type IV collagenase and gelatinase A, MMP-2 is an enzyme thatin humans is encoded by the MMP2 gene. The MMP2 gene is on chromosome 16at position 12.2.

The second factor may be matrix metalloproteinase 9 (MMP-9). Also knownas 92 kDa type IV collagenase, 92 kDa gelatinase or gelatinase B (GELB),MMP-9 is a matrixin, a class of enzymes that belong to thezinc-metalloproteinases family involved in degrading the extracellularmatrix. In humans, the MMP9 gene encodes for a signal peptide, apropeptide, a catalytic domain with inserted three repeats offibronectin type II domain followed by a C-terminal hemopexin-likedomain.

The second factor may be neuropilin-1 (NRP-1) is a protein that inhumans is encoded by the NRP1 gene. In humans, the neuropilin 1 gene isat 10p11.22.

The second factor may be neuropilin-2 (NRP-2). NRP-2 is a protein thatin humans is encoded by the NRP2 gene. This gene encodes a member of theneuropilin family of receptor proteins. The encoded transmembraneprotein binds to SEMA3C protein {sema domain, immunoglobulin domain(Ig), short basic domain, secreted, (semaphorin) 3C} and SEMA3F protein{sema domain, immunoglobulin domain (Ig), short basic domain, secreted,(semaphorin) 3F}, and interacts with vascular endothelial growth factor(VEGF). This protein may play a role in cardiovascular development, axonguidance, and tumorigenesis. Multiple transcript variants encodingdistinct isoforms have been identified for this gene.

The second factor may be platelet-derived growth factor (PDGF) is one ofmany growth factors that regulate cell growth and division. PDGF plays asignificant role in blood vessel formation (angiogenesis), the growth ofblood vessels from already-existing blood vessel tissue, mitogenesis,i.e. proliferation, of mesenchymal cells such as fibroblasts,osteoblasts, tenocytes, vascular smooth muscle cells and mesenchymalstem cells as well as chemotaxis, the directed migration, of mesenchymalcells. Platelet-derived growth factor is a dimeric glycoprotein that canbe composed of two A subunits (PDGF-AA), two B subunits (PDGF-BB), orone of each (PDGF-AB).

The second factor may be phosphatidylinositol-glycan biosynthesis classF protein (PIGF).

The second factor may be placental growth factor (PGF), a protein thatin humans is encoded by the PGF gene. PGF is a member of the VEGF(vascular endothelial growth factor) sub-family. The main source of PGFduring pregnancy is the placental trophoblast. PGF is also expressed inmany other tissues, including the villous trophoblast.

The second factor may be tyrosine kinase with immunoglobulin-like andEGF-like domains 1 and 2 (TIE1/2), which is an angiopoietin receptorwhich in humans is encoded by the TIE1 gene.

The second factor may be vascular endothelial growth factor A (VEGF-A).The second factor may be vascular endothelial growth factor C (VEGF-C).The second factor may be vascular endothelial growth factor D (VEGF-D).

The lymphatic system may be assessed from elevated levels measured usinga flow-cytometry-based multiplex assay or an enzyme-linked immunosorbentassay. The lymphatic system may be assessed from elevated levelsmeasured using a flow-cytometry-based multiplex assay. The lymphaticsystem may be assessed from elevated levels measured using anenzyme-linked immunosorbent assay.

The lymphatic system may be assessed from expression levels measured byone or more techniques chosen from immunohistochemistry, gene expressionprofiling, and polymerase chain reaction (PCR)-based cDNA amplificationof a lymphangiogenesis-regulating gene. The lymphatic system may beassessed from expression levels measured by immunohistochemistry. Thelymphatic system may be assessed from expression levels measured by geneexpression profiling. The lymphatic system may be assessed fromexpression levels measured by polymerase chain reaction (PCR)-based cDNAamplification of a lymphangiogenesis-regulating gene.

The lymphangiogenesis-regulating gene may be one or more selected fromthe group selected from angiopoietin-1, angiopoietin-2, BMP-9, EGF,endoglin, endothelin-1, FGF-1, FGF-2, follistatin, G-CSF, HB-EGF, HGF,IGF, IL-8, leptin, MMP-2, MMP-9, NRP 1, NRP 2, PDGF, PIGF, PLGF, TIE1/2,VEGF-A, VEGF-C, and VEGF-D. The lymphangiogenesis-regulating gene may beangiopoietin-1. The lymphangiogenesis-regulating gene may beangiopoietin-2. The lymphangiogenesis-regulating gene may be BMP-9. Thelymphangiogenesis-regulating gene may be EGF. Thelymphangiogenesis-regulating gene may be endoglin. Thelymphangiogenesis-regulating gene may be endothelin-1. Thelymphangiogenesis-regulating gene may be FGF-1. Thelymphangiogenesis-regulating gene may be FGF-2. Thelymphangiogenesis-regulating gene may be follistatin. Thelymphangiogenesis-regulating gene may be G-CSF. Thelymphangiogenesis-regulating gene may be HB-EGF. Thelymphangiogenesis-regulating gene may be HGF. Thelymphangiogenesis-regulating gene may be IGF. Thelymphangiogenesis-regulating gene may be IL-8. Thelymphangiogenesis-regulating gene may be leptin. Thelymphangiogenesis-regulating gene may be MMP-2. Thelymphangiogenesis-regulating gene may be MMP-9. Thelymphangiogenesis-regulating gene may be NRP 1. Thelymphangiogenesis-regulating gene may be NRP 2. Thelymphangiogenesis-regulating gene may be PDGF. Thelymphangiogenesis-regulating gene may be PIGF. Thelymphangiogenesis-regulating gene may be PLGF. Thelymphangiogenesis-regulating gene may be TIE1/2. Thelymphangiogenesis-regulating gene may be VEGF-A. Thelymphangiogenesis-regulating gene may be VEGF-C. Thelymphangiogenesis-regulating gene may be VEGF-D.

The lymphatic system may be assessed by profiling immune cells directlyin a specimen by flow cytometry, mass spectrometry, cell labeling, orany combination thereof. The lymphatic system may be assessed byprofiling immune cells directly in a specimen by flow cytometry. Thelymphatic system may be assessed by profiling immune cells directly in aspecimen by mass spectrometry. The lymphatic system may be assessed byprofiling immune cells directly in a specimen cell labeling.

The lymphatic system may be assessed by measuring one or more markersselected from the group selected from angiopoietin-1, angiopoietin-2,heparin-binding factor midkine, BMP-9, EGF, endoglin, endothelin-1,FGF-1, FGF-2, follistatin, G-CSF, HB-EGF, HGF, IGF, IL-8, leptin, MMP-2,MMP-9, NRP 1, NRP 2, PDGF, PIGF, PLGF, TIE1/2, VEGF-A, VEGF-C, andVEGF-D. The marker may be angiopoietin-1. The marker may beangiopoietin-2. The marker may be heparin-binding factor midkine. Themarker may be BMP-9. The marker may be EGF. The marker may be endoglin.The marker may be endothelin-1. The marker may be FGF-1. The marker maybe FGF-2. The marker may be follistatin. The marker may be G-CSF. Themarker may be HB-EGF. The marker may be HGF. The marker may be IGF. Themarker may be IL-8. The marker may be leptin. The marker may be MMP-2.The marker may be MMP-9. The marker may be NRP 1. The marker may be NRP2. The marker may be PDGF. The marker may be PIGF. The marker may bePLGF. The marker may be TIE1/2. The marker may be VEGF-A. The marker maybe VEGF-C. The marker may be VEGF-D.

The dysregulated lymphatic system may be characterized by one or morechosen from abnormal lymphatic development, lymphatic proliferation,lymphangiogenesis, impaired lymphatic vessel function, dysregulatedlymphatic vessel function, augmented tumor cell lymphatic infiltration,lymphangitic carcinomatosis, abnormal functioning or homeostaticregulation, lymphatic remodeling, physical pressure upon lymphatics,altered tumoral lymphatic development, altered tumorallymphangiogenesis, and output blockage of lymphatic structures inlymphatic organs. The dysregulated lymphatic system may be characterizedby abnormal lymphatic development. The dysregulated lymphatic system maybe characterized by lymphatic proliferation. The dysregulated lymphaticsystem may be characterized by lymphangiogenesis. The dysregulatedlymphatic system may be characterized by impaired lymphatic vesselfunction. The dysregulated lymphatic system may be characterized bydysregulated lymphatic vessel function. The dysregulated lymphaticsystem may be characterized by augmented tumor cell lymphaticinfiltration. The dysregulated lymphatic system may be characterized bylymphangitic carcinomatosis. The dysregulated lymphatic system may becharacterized by abnormal functioning or homeostatic regulation. Thedysregulated lymphatic system may be characterized by lymphaticremodeling. The dysregulated lymphatic system may be characterized byphysical pressure upon lymphatics. The dysregulated lymphatic system maybe characterized by altered tumoral lymphatic development. Thedysregulated lymphatic system may be characterized by altered tumorallymphangiogenesis. The dysregulated lymphatic system may becharacterized by output blockage of lymphatic structures in lymphaticorgans.

Further, based on evaluation of the status of the lymphatic system inthe cancer subject, the potential treatment with an immune-modulatingtherapy is assessed. If subjects are determined to have dysregulation oftheir lymphatic system from abnormal lymphatic system featuresindependent of PD-1 or PD-L1, then the treatment with anyimmune-modulating therapy that depends on efficient immune cell primingor antigen presentation is either aborted, deferred, or is augmented bya treatment method that modulates the lymphatic system to overcome oroffset the dysfunctions.

B. Immune Modulating Therapy

The immune modulating therapy may be chosen from an antagonist forimmune checkpoint inhibition, an agonist for immune co-stimulationsignal, a stimulatory factor affecting immune cell priming andactivation, a chemotactic agent, cytokine-related immune modulator,chemotherapeutic immune stimulation, radiotherapeutic immunestimulation, a vaccine, activation of an adaptive immune response, andactivation of an innate immune response. Immune modulating therapy thatwork independent of immune cell priming and antigen presentation includeadoptive cell transfer and immune cell modification strategies, such aschimeric antigen receptor T cell (CAR-T) therapy. Here, immune cells arechanged (1) intrinsically (in vivo modification which would includevaccination-based approaches and the like), (2) extrinsically viaadoptive cell therapies or immune cell modification strategies, such asvia CAR-T therapy, immune cell grafting, immune cell transplantation, orstem cell transplantation, and related strategies, and any combinationof intrinsic or extrinsic modification.

The immune modulating therapy may be an antagonist for immune checkpointinhibition. The immune modulating therapy may be an agonist for immuneco-stimulation signal. The immune modulating therapy may be astimulatory factor affecting immune cell priming and activation. Theimmune modulating therapy may be a chemotactic agent. The immunemodulating therapy may be cytokine-related immune modulator. The immunemodulating therapy may be chemotherapeutic immune stimulation. Theimmune modulating therapy may be radiotherapeutic immune stimulation.The immune modulating therapy may be a vaccine. The immune modulatingtherapy may be activation of an adaptive immune response. The immunemodulating therapy may be activation of an innate immune response.

The immune modulating therapy may be an antagonist for immune checkpointinhibition having a target chosen from PD-1, PD-L1, CTLA-4, LAG3, TIM-2,CD47, KIR, TIM3, and CD30.

The target may be programmed death receptor 1 (PD-1), also known as andCD279 (cluster of differentiation 279). PD-1 is a cell surface receptorthat downregulates the immune system and promote self-tolerance bysuppressing T cell inflammatory activity. PD-1 is an immune checkpointand guards against autoimmunity through a dual mechanism of promotingapoptosis (programmed cell death) in antigen specific T-cells in lymphnodes while simultaneously reducing apoptosis in regulatory T cells(anti-inflammatory, suppressive T cells). PD-1 inhibits the immunesystem. This prevents autoimmune diseases, but it can also prevent theimmune system from killing cancer cells. Drugs that block PD-1, the PD-1inhibitors, activate the immune system to attack tumors PD-1 is a cellsurface receptor that belongs to the immunoglobulin superfamily and isexpressed on T cells and pro-B cells. PD-1 binds two ligands, PD-L1 andPD-L2.

The target may be programmed death-ligand 1 (PD-L1). Also known ascluster of differentiation 274 (CD274) or B7 homolog 1 (B7-H1), PD-L1 isa protein that in humans is encoded by the CD274 gene. Programmeddeath-ligand 1 (PD-L1) is a 40 kDa type 1 transmembrane protein maysuppress the immune system during pregnancy, tissue allografts,autoimmune disease, and hepatitis. Normally, the immune system reacts toforeign antigens associated with exogenous or endogenous danger signals,which trigger a proliferation of antigen-specific CD8+ T cells and/orCD4+ helper cells. The binding of PD-L1 to PD-1 or B7.1 transmits aninhibitory signal that reduces the proliferation of these T cells andcan also induce apoptosis, which is further mediated by a lowerregulation of the gene Bcl-2.

The target may be cytotoxic T-lymphocyte-associated protein 4 (CTLA-4),also known as CD152 (cluster of differentiation 152). CTLA-4 is aprotein receptor that, functioning as an immune checkpoint,downregulates immune responses. CTLA4 is constitutively expressed inregulatory T cells but only upregulated in conventional T cells afteractivation.

The target may be lymphocyte-activation gene 3 (LAG-3), a protein whichin humans is encoded by the LAG3 gene. LAG3 is also designated CD223(cluster of differentiation 223). LAG3 is a cell surface molecule withdiverse biologic effects on T cell function. It is an immune checkpointreceptor.

The target may be T cell immunoglobulin and mucin domain family 2(TIM-2) for family 3 (TIM3).

The target may be Cluster of Differentiation 47 (CD47), also known asintegrin associated protein (TAP). CD47 is a transmembrane protein thatin humans is encoded by the CD47 gene. CD47 belongs to theimmunoglobulin superfamily and partners with membrane integrins andbinds the ligands thrombospondin-1 (TSP-1) and signal-regulatory proteinalpha (SIRPα). This is because the protein IAP produced by CD-47 acts asa don't eat me signal to the immune system and drives organ fibrosis.CD47 is involved in many cellular processes, including apoptosis,proliferation, adhesion, and migration. Furthermore, it plays a key rolein immune and angiogenic responses. CD47 is ubiquitously expressed inhuman cells and has been found to be overexpressed in many differenttumor cells. Expression in equine cutaneous tumors has been reported aswell.

The target may be killer-cell immunoglobulin-like receptors (KIR), afamily of type I transmembrane glycoproteins expressed on the plasmamembrane of natural killer (NK) cells and a minority of T cells.

The target may be CD30. CD30, also known as TNFRSF8, is a cell membraneprotein of the tumor necrosis factor receptor family and tumor marker.This receptor is expressed by activated, but not by resting, T and Bcells. TRAF2 and TRAF5 can interact with this receptor, and mediate thesignal transduction that leads to activating NF-kappaB. It is a positiveregulator of apoptosis, limits the proliferative potential ofautoreactive CD8 effector T cells, and protect the body againstautoimmunity. Two alternatively spliced transcript variants of this geneencoding distinct isoforms have been reported.

The immune modulating therapy may be an agonist for immuneco-stimulation signal having a target chosen from CD137/41BB, 41BBL,OX40, CD27, CD40/CD40L/cd40/CEA-CD3CD, and STING.

The target may be CD137/41BB. CD137 is a member of the tumor necrosisfactor (TNF) receptor family. Its alternative names are tumor necrosisfactor receptor superfamily member 9 (TNFRSF9), 4-1BB and induced bylymphocyte activation (ILA). CD137 can be expressed by activated Tcells, but on CD8 than on CD4 T cells. In addition, CD137 expression isfound on dendritic cells, B cells, follicular dendritic cells, naturalkiller cells, granulocytes and cells of blood vessel walls at sites ofinflammation.

The target may be 4-1BB, a type 2 transmembrane glycoprotein belongingto the TNF superfamily, expressed on activated T lymphocytes. 41BBL isthe ligand for 4-1BB.

The target may be OX40. Tumor necrosis factor receptor superfamily,member 4 (TNFRSF4), also known as CD134 and OX40 receptor, is a memberof the TNFR-superfamily of receptors which is not constitutivelyexpressed on resting naïve T cells, unlike CD28. OX40 is a secondaryco-stimulatory immune checkpoint molecule, expressed after 24 to 72hours following activation; its ligand, OX40L, is also not expressed onresting antigen presenting cells, but is following their activation.Expression of OX40 is dependent on full activation of the T cell;without CD28, expression of OX40 is delayed and of fourfold lowerlevels.

ICOS, or CD278, is the inducible T-cell costimulatory, an immunecheckpoint protein that in humans is encoded by the ICOS gene. ICOS is aCD28-superfamily costimulatory molecule that is expressed on activated Tcells. It is thought to be important for T_(h)2 cells.

The target may be cluster of differentiation 27 (CD27), a member of thetumor necrosis factor receptor superfamily and a co-stimulatory immunecheckpoint molecule. The protein encoded by this gene is a member of theTNF-receptor superfamily. This receptor is needed for generation andlong-term maintenance of T cell immunity. It binds to ligand CD70, andregulate B-cell activation and immunoglobulin synthesis. This receptortransduces signals that lead to activating NF-κB and MAPK8/JNK. Adaptorproteins TRAF2 and TRAF5 have been shown to mediate the signalingprocess of this receptor. CD27-binding protein (SIVA), a proapoptoticprotein, can bind to this receptor and induces apoptosis by thisreceptor.

The target may be cluster of differentiation 40 or its ligandCD40/CD40L/cd40/CEA-CD3CD. CD40 is a costimulatory protein found onantigen presenting cells and is needed for their activation. BindingCD154 (CD40L) on TH cells to CD40 activates antigen presenting cells andinduces a variety of downstream effects. Deficiency can cause Hyper-IgMsyndrome type 3.

The target may be stimulator of interferon genes (STING), also known astransmembrane protein 173 (TMEM173) and MPYS/MITA/ERIS. STING is aprotein that in humans is encoded by the TMEM173 gene.

The immune modulating therapy may be a stimulatory factor affectingimmune cell priming and activation chosen from CD28/B7.1, CD137/CD137L,OX40/OX40L, CD27/CD70, HVEM, GITR, CDN, ATB, HMGB1, TLR4, LR7, TLR 8,TLR9, MICA/MICB, B7-H2, B7-H3, B7-H4, and B7-1/2.

The stimulatory factor may be Cluster of Differentiation 28(CD28/B7.1),one proteins expressed on T cells that provide co-stimulatory signalsfor T cell activation and survival. T cell stimulation through CD28 inaddition to the T-cell receptor (TCR) can provide a potent signal forproducing various interleukins (IL-6 in particular). CD28 is thereceptor for CD80 (B7.1) and CD86 (B7.2) proteins. When activated byToll-like receptor (TLR) ligands, the CD80 expression is upregulated inantigen presenting cells (APCs). The CD86 expression on antigenpresenting cells is constitutive (expression is independent ofenvironmental factors). CD28 is the only B7 receptor constitutivelyexpressed on naive T cells. Association of the TCR of a naive T cellwith MHC:antigen complex without CD28:B7 interaction results in a T cellthat is anergic.

The stimulatory factor may be CD137/CD137L. CD137 is a member of thetumor necrosis factor (TNF) receptor family. Its alternative names aretumor necrosis factor receptor superfamily member 9 (TNFRSF9), 4-1BB andinduced by lymphocyte activation (ILA). CD137 is a co-stimulatory immunecheckpoint molecule.

The stimulatory factor may be OX40/OX40L. The stimulatory factor may beCD27/CD70.

The stimulatory factor may be herpesvirus entry mediator (HVEM), alsoknown as tumor necrosis factor receptor superfamily member 14(TNFRSF14), is a human cell surface receptor of the TNF-receptorsuperfamily.

The stimulatory factor may be GITR. Tumor necrosis factor receptorsuperfamily member 18 (TNFRSF18) also known as activation-inducible TNFRfamily receptor (AITR) or glucocorticoid-induced TNFR-related protein(GITR) is a protein that in humans is encoded by the TNFRSF18 gene. GITRis a co-stimulatory immune checkpoint molecule.

The stimulatory factor may be CDN. The stimulatory factor may be ATB.

The stimulatory factor may be high mobility group box 1 protein, alsoknown as high-mobility group protein 1 (HMG-1) and amphoterin, a proteinthat in humans is encoded by the HMGB1 gene. In the nucleus HMGB1interacts with nucleosomes, transcription factors, and histones. Thisnuclear protein organizes the DNA and regulates transcription. Afterbinding, HMGB1 bends DNA, which aids binding of other proteins. HMGB1supports transcription of many genes in interactions with manytranscription factors. It also interacts with nucleosomes to loosenpacked DNA and remodel the chromatin. Contact with core histones changesthe structure of nucleosomes. HMGB1 in the nucleus depends onposttranslational modifications. When the protein is not acetylated, itstays in the nucleus, but hyperacetylation on lysine residues causes itto translocate into the cytosol. HMGB1 has been shown to play animportant role in helping the RAG endonuclease form a paired complexduring V(D)J recombination. HMG-1 belongs to high mobility group andcontains HMG-box domain.

The stimulatory factor may be toll-like receptor 4 (TLR4). atransmembrane member of the toll-like receptor family, which belongs tothe pattern recognition receptor (PRR) family. Its activation leads toan intracellular signaling pathway NF-κB and inflammatory cytokineproduction responsible for activating the innate immune system. TLR4 ismost well-known for recognizing lipopolysaccharide (LPS), a componentpresent in many Gram-negative bacteria (e.g. Neisseria spp.) and selectGram-positive bacteria. Its ligands also include several viral proteins,polysaccharide, and a variety of endogenous proteins such as low-densitylipoprotein, beta-defensins, and heat shock protein. TLR4 has also beendesignated as CD284 (cluster of differentiation 284).

The stimulatory factor may be toll-like receptor 7 (TLR7), a proteinthat in humans is encoded by the TLR7 gene. TLR7 recognizessingle-stranded RNA in endosomes, a common feature of viral genomeswhich are internalized by macrophages and dendritic cells. TLR7recognizes single-stranded RNA of viruses such as HIV and HCV. TLR7 canrecognize GU-rich single-stranded RNA. However, the presence of GU-richsequences in the single-stranded RNA is not enough to stimulate TLR7.

The stimulatory factor may be toll-like receptor 8 (TLR8). Also known ascluster of differentiation 288 (CD288), TLR8 a protein that in humans isencoded by the TLR8 gene. TLR8 can recognize GU-rich single-strandedRNA. However, the presence of GU-rich sequences in the single-strandedRNA is not enough to stimulate TLR8. TLR8 recognizes G-richoligonucleotides. TLR8 is an endosomal receptor that recognizes singlestranded RNA (ssRNA), and can recognize ssRNA viruses such as Influenza,Sendai, and Coxsackie B viruses. TLR8 binding to the viral RNA recruitsMyD88 and leads to activation of the transcription factor NF-κ3 and anantiviral response. TLR8 recognizes single-stranded RNA of viruses suchas HIV and HCV.

The stimulatory factor may be toll-like receptor 9 (TLR9), also known asCD289 (cluster of differentiation 289). TLR9 is a member of thetoll-like receptor (TLR) family. TLR9 is an important receptor expressedin immune system cells including dendritic cells, macrophages, naturalkiller cells, and other antigen presenting cells. TLR9 preferentiallybinds DNA present in bacteria and viruses, and triggers signalingcascades that lead to a pro-inflammatory cytokine response. Cancer,infection, and tissue damage can all modulate TLR9 expression andactivation. TLR9 is also an important factor in autoimmune diseases, andthere is active research into synthetic TLR9 agonists and antagoniststhat help regulate autoimmune inflammation.

The stimulatory factor may be major histocompatibility complex (MHC)class I polypeptide-related sequence A (MICA) is a cell surfaceglycoprotein encoded by the MICA gene within MHC locus. MICA is relatedto MHC class I and has similar domain structure, which is made up ofexternal α1α2α3 domain, transmembrane segment and C-terminal cytoplasmictail. However, MICA is not associated with β2-microglobulin nor bindspeptides as conventional MHC class I molecules do. MICA works as astress-induced ligand for NKG2D receptor. For example, the heat shockstress pathway regulates MICA expression as transcription of MICA isregulated by promoter heat shock element. MICA is broadly recognized byNK cells, γδ T cells, and CD8+αβ T cells which carry NKG2D receptor ontheir cell surface. Because of NKG2D-MICA engagement, effector cytolyticresponses of T cells and NK cells against epithelial tumor cellsexpressing MICA are started.

The stimulatory factor may be major histocompatibility complex (MHC)class I polypeptide-related sequence B (MICB) is a protein that isencoded by the MICB gene within MHC locus. MICB is related to MHC classI and has similar domain structure, which is made up of external α1α2α3domain, transmembrane segment and C-terminal cytoplasmic tail. MICB is astress-induced ligand for NKG2D receptor. The heat shock stress pathwayis involved in the regulation of MICB expression as transcription ofMICB is regulated by promoter heat shock element.

The stimulatory factor may be a B7 protein. B7 is a type of peripheralmembrane protein found on activated antigen presenting cells (APC) that,when paired with either a CD28 or CD152 (CTLA-4) surface protein on a Tcell, can produce a costimulatory signal or a coinhibitory signal toenhance or decrease the activity of a MHC-TCR signal between the APC andthe T cell, respectively. Binding the B7 of APC to CTLA-4 of T-cellscauses inhibition of the activity of T-cells. There are two major typesof B7 proteins: B7-1 or CD80, and B7-2 or CD86. However, it is not knownif they differ significantly from each other. CD28 and CTLA-4 eachinteract with both B7-1 and B7-2. The stimulatory factor may be B7-H2.The stimulatory factor may be B7-H3. The stimulatory factor may beB7-H4. The stimulatory factor may be B7-1/2.

The immune modulating therapy may be a chemotactic agent chosen fromCX3CL1, CXCL9, CXCL10, CCL5, LFA1, ICAM1, selectin E, selectin P,selectin N, CXCR4, CCR2, CCL21, CCR5, CXCR1, CXCR2, CSF1R, and CCR4. Thechemotactic agent may be a chemokine, a small protein that regulatescell trafficking of leukocytes. The chemokines also play fundamentalroles in the development, homeostasis, and function of the immunesystem, and they have effects on cells of the central nervous system aswell as on endothelial cells involved in angiogenesis or angiostasis.

The chemotactic agent may be CX3CL1. Fractalkine, also known aschemokine (C-X3-C motif) ligand 1, is a protein that in humans isencoded by the CX3CL1 gene. Fractalkine is a large cytokine protein of373 amino acids, it has multiple domains and is the only known member ofthe CX3C chemokine family. The polypeptide structure of CX3CL1 differsfrom the typical structure of other chemokines.

The chemotactic agent may be chemokine (C-X-C motif) ligand 9 (CXCL9), asmall cytokine belonging to the CXC chemokine family that is also knownas monokine induced by gamma interferon (MIG). CXCL9 is a T-cellchemoattractant, which is induced by IFN-γ. It is closely related to twoother CXC chemokines called CXCL10 and CXCL11, whose genes are near thegene for CXCL9 on human chromosome 4. CXCL9, CXCL10 and CXCL11 allelicit their chemotactic functions by interacting with the chemokinereceptor CXCR3. Neutrophil collagenase/matrix metalloproteinase 8(MMP-8) degrades CXCL9 and cleaves CXCL10 at two positions. GelatinaseB/matrix metalloproteinase 9 (MMP-9) degrades CXCL10 and cleaves CXCL9at three different sites in its extended carboxy-terminal region.

The chemotactic agent may be C-X-C motif chemokine 10 (CXCL10), alsoknown as interferon gamma-induced protein 10 (IP-10) or small-induciblecytokine B10. CXCL10 is an 8.7 kDa protein that in humans is encoded bythe CXCL10 gene.

The chemotactic agent may be chemokine (C-C motif) ligand 5 (CCL5), aprotein which in humans is encoded by the CCL5 gene. It is also known asRANTES (regulated on activation, normal T cell expressed and secreted).

The chemotactic agent may be lymphocyte function-associated antigen 1(LFA-1), found on T-cells, B-cells, macrophages, neutrophils and NKcells. LFA1 is involved in recruitment to the site of infection. Itbinds to ICAM-1 on antigen-presenting cells and functions as an adhesionmolecule. LFA-1 is the first to bind T-cells to antigen-presenting cellsand initially binds weakly. A signal from the T-cell receptor and/or thecytokine receptor changes the conformation and prolongs the cellcontact, allowing the T-cell to proliferate. LFA-1/ICAM-1 interactionleads to further T cell differentiation. LFA-1 is part of the family ofleukocyte integrins recognized by their common β-chains (β2, CD18).LFA-1 also has a distinct α-chain (αL, CD11a).

The chemotactic agent may be Intercellular Adhesion Molecule 1 (ICAM-1),also known as CD54 (Cluster of Differentiation 54). ICAM-1 is a proteinthat in humans is encoded by the ICAM1 gene, giving a cell surfaceglycoprotein typically expressed on endothelial cells and cells of theimmune system. It binds to integrins of type CD11a/CD18, or CD11b/CD18and is also exploited by rhinovirus as a receptor.

The chemotactic agent may be one or more selectins. The selectins(cluster of differentiation 62 or CD62) are a family of cell adhesionmolecules (or CAMs). All selectins are single-chain transmembraneglycoproteins that share similar properties to C-type lectins due to arelated amino terminus and calcium-dependent binding. Selectins bind tosugar moieties and so are a type of lectin, cell adhesion proteins thatbind sugar polymers. The chemotactic agent may be selectin E. Thechemotactic agent may be selectin P. The chemotactic agent may beselectin N.

The chemotactic agent may be CXCR4. C-X-C chemokine receptor type 4(CXCR-4) also known as fusin or CD184 (cluster of differentiation 184)is a protein that in humans is encoded by the CXCR4 gene.

The chemotactic agent may be C-C chemokine receptor type 2 (CCR2) alsoknown as cluster of differentiation 192 (CD192), a protein that inhumans is encoded by the CCR2 gene. CCR2 is a chemokine receptor. Thisgene encodes two isoforms of a receptor for monocyte chemoattractantprotein-1 (CCL2), a chemokine which specifically mediates monocytechemotaxis. Monocyte chemoattractant protein-1 is involved in monocyteinfiltration in inflammatory diseases, such as rheumatoid arthritis, andin the inflammatory response against tumors. The receptors encoded bythis gene mediate agonist-dependent calcium mobilization and inhibitionof adenylyl cyclase.

The chemotactic agent may be chemokine (C-C motif) ligand 21 (CCL21), asmall cytokine belonging to the CC chemokine family. This chemokine isalso known as 6Ckine (because it has six conserved cysteine residuesinstead of the four cysteines typical to chemokines), exodus-2, andsecondary lymphoid-tissue chemokine (SLC). The gene for CCL21 is onhuman chromosome 9. CCL21 elicits its effects by binding to a cellsurface chemokine receptor known as CCR7.

The chemotactic agent may be C-C chemokine receptor type 5 (CCR5), alsoknown as cluster of differentiation 195 (CD195), a protein on thesurface of white blood cells involved in the immune system, as it actsas a receptor for chemokines. This is the process by which T cells areattracted to specific tissue and organ targets. Many forms of HIV, thevirus that causes AIDS, initially use CCR5 to enter and infect hostcells. Certain individuals carry a CCR5-Δ32 mutation in the CCR5 gene,protecting them against these strains of HIV.

The chemotactic agent may be C-X-C motif chemokine receptor 1 (CXCR1),also known as interleukin 8 receptor, alpha (IL8RA) and cluster ofdifferentiation 181 (CD181). The protein encoded by this gene is amember of the G-protein-coupled receptor family. This protein is areceptor for interleukin 8 (IL8). It binds to IL8 with high affinity,and transduces the signal through a G-protein-activated second messengersystem. Knockout studies in mice suggested that this protein inhibitsembryonic oligodendrocyte precursor migration in developing spinal cord.This gene, IL8RB, a gene encoding another high affinity IL8 receptor,and IL8RBP, a pseudogene of IL8RB, form a gene cluster in a regionmapped to chromosome 2q33-q36. Stimulation of CXCR1 in neutrophils byits primary ligand, Interleukin 8, leads to neutrophil chemotaxis andactivation.

The chemotactic agent may be CXCR2, also known as interleukin 8receptor, beta (IL8RB). The protein encoded by this gene is a member ofthe G-protein-coupled receptor family. This protein is a receptor forinterleukin 8 (IL8). It binds to IL8 with high affinity, and transducesthe signal through a G-protein-activated second messenger system(Gi/o-coupled). This receptor also binds to chemokine (C-X-C motif)ligand 1 (CXCL1/MGSA), a protein with melanoma growth stimulatingactivity, and is a major component for serum-dependent melanoma cellgrowth. In addition, it binds ligands CXCL2, CXCL3, and CXCL5. Theangiogenic effects of IL8 in intestinal microvascular endothelial cellsare found to be mediated by this receptor. Knockout studies in micesuggested that this receptor controls the positioning of oligodendrocyteprecursors in developing spinal cord by arresting their migration. Thisgene, IL8RA, a gene encoding another high affinity IL8 receptor, andIL8RBP, a pseudogene of IL8RB, form a gene cluster in a region mapped tochromosome 2q33-q36. Mutations in CXCR2 cause hematological traits.

The chemotactic agent may be colony stimulating factor 1 receptor(CSF1R), also known as macrophage colony-stimulating factor receptor(M-CSFR), and CD115 (Cluster of Differentiation 115), a cell-surfaceprotein encoded, in humans, by the CSF1R gene (known also as c-FMS). Itis a receptor for a cytokine called colony stimulating factor 1. Theencoded protein is a single pass type I membrane protein and acts as thereceptor for colony stimulating factor 1, a cytokine which controls theproduction, differentiation, and function of macrophages. This receptormediates most, if not all, of the biological effects of this cytokine.Ligand binding activates CSF1R through a process of oligomerization andtrans-phosphorylation. The encoded protein is a tyrosine kinasetransmembrane receptor and member of the CSF1/PDGF receptor family oftyrosine-protein kinases.

The chemotactic agent may be CCR4. C-C chemokine receptor type 4 is aprotein that in humans is encoded by the CCR4 gene. CCR4 has alsorecently been designated CD194 (cluster of differentiation 194). Theprotein encoded by this gene belongs to the G protein-coupled receptorfamily. It is a receptor for the CC chemokines CCL2 (MCP-1), CCL4(MIP-1), CCL5 (RANTES), CCL17 (TARC), and CCL22 (Macrophage-derivedchemokine).

The immune modulating therapy may be a chemotactic agent comprising acytokine chosen from IL-1, IL-2, IL-4, IL-6, IL-7, IL-8, IL-13, IL-12,interferon gamma, IFNa, TNFa, CSF1, CSF1R, and GM-CSF.

The chemotactic agent may be the interleukin-1 family (IL-1 family), agroup of 11 cytokines, which regulate immune and inflammatory responsesto infections or sterile insults.

The chemotactic agent may be interleukin 2 (IL-2), a cytokineglycoprotein that stimulates the growth of T cell lymphocytes andprovides other biochemical signaling to the immune system.

The chemotactic agent may be interleukin 4 (IL4, IL-4), a cytokine thatinduces differentiation of naive helper T cells (Th0 cells) to Th2cells. Upon activation by IL-4, Th2 cells then produce more IL-4 in apositive feedback loop. Basophils may initially produce IL-4, thusinducing Th0 differentiation. IL-2 is closely related and has functionslike interleukin 13.

The chemotactic agent may be interleukin 6 (IL-6), a pro-inflammatorycytokine.

The chemotactic agent may be interleukin 7 (IL-7), a protein that inhumans is encoded by the IL7 gene. IL-7 is a hematopoietic growth factorsecreted by stromal cells in the bone marrow and thymus. IL-7 is alsoproduced by keratinocytes, dendritic cells, hepatocytes, neurons, andepithelial cells, but not by normal lymphocytes.

The chemotactic agent may be interleukin 8 (IL-8), a chemokine of theimmune system

The chemotactic agent may be interleukin 13 (IL-13), a protein that inhumans is encoded by the IL13 gene. IL-13 is on chromosome 5q31 with alength of 1.4 kb. IL-13 and IL-4 show a 30% of sequence similarity andhave a similar structure. IL-13 is cytokine secreted by many cell types,but especially T helper type 2 (Th2) cells; that is, a mediator ofallergic inflammation and disease.

The chemotactic agent may be interleukin 12 (IL-12), an interleukinnaturally produced by dendritic cells, macrophages, neutrophils, andhuman B-lymphoblastoid cells (NC-37) in response to antigenicstimulation. IL-12 is involved in the differentiation of naive T cellsinto Th1 cells. IL-12 is known as a T cell-stimulating factor, which canstimulate the growth and function of T cells. It stimulates theproduction of interferon-gamma (IFN-γ) and tumor necrosis factor-alpha(TNF-α) from T cells and natural killer (NK) cells, and reduces IL-4mediated suppression of IFN-γ. T cells that produce IL-12 have acoreceptor, CD30, which is associated with IL-12 activity.

The chemotactic agent may be interferon gamma (IFNγ), a dimerizedsoluble cytokine and is the only member of the type II class ofinterferons.

The chemotactic agent may be IFN-α, which are proteins are produced byleukocytes. They are involved in innate immune response against viralinfection. The genes responsible for their synthesis come in 13 subtypescalled IFNA1, IFNA2, IFNA4, IFNA5, IFNA6, IFNA7, IFNA8, IFNA10, IFNA13,IFNA14, IFNA16, IFNA17, IFNA21. These genes are found together in acluster on chromosome 9. The recombinant type is interferon alfacon-1.The PEGylated types are PEGylated interferon alfa-2a and PEGylatedinterferon alfa-2b.

The chemotactic agent may be tumor necrosis factor (TNF, tumor necrosisfactor alpha, TNFα, cachexin, or cachectin), a cell signaling protein(cytokine) involved in systemic inflammation. TNFα is one cytokines thatmakes up the acute phase reaction. TNFα is produced chiefly by activatedmacrophages, although it can be produced by many other cell types suchas CD4+ lymphocytes, NK cells, neutrophils, mast cells, eosinophils, andneurons. TNF primarily regulates immune cells. TNF, being an endogenouspyrogen, can induce fever, apoptotic cell death, cachexia, inflammationand to inhibit tumorigenesis and viral replication and respond to sepsisvia IL1 and IL6 producing cells. Dysregulation of TNF production hasbeen implicated in a variety of human diseases including Alzheimer'sdisease, cancer, major depression, psoriasis and inflammatory boweldisease (IBD). Though controversial, studies of depression and IBD arelinked to TNF levels. Recombinant TNF is used as an immunostimulantunder the INN tasonermin. TNF can be produced ectopically in the settingof malignancy and parallels parathyroid hormone both in causingsecondary hypercalcemia and in the cancers with which excessiveproduction is associated.

The chemotactic agent may be CSF1. The chemotactic agent may be CSF1R.

The chemotactic agent may be granulocyte-macrophage colony-stimulatingfactor (GM-CSF), also known as colony stimulating factor 2 (CSF2), amonomeric glycoprotein secreted by macrophages, T cells, mast cells,natural killer cells, endothelial cells and fibroblasts that functionsas a cytokine. The pharmaceutical analogs of naturally occurring GM-CSFare called sargramostim and molgramostim. Unlike granulocytecolony-stimulating factor, which specifically promotes neutrophilproliferation and maturation, GM-CSF affects more cell types, especiallymacrophages and eosinophils.

The immune modulating therapy may be chemotherapeutic immune stimulationchosen from cyclophosphamide, paclitaxel, doxorubicin, TDO2, IDO, ARG1,ARG2, PDE5, P2X7 inhibitor, P2Y11 inhibitor, A2A Receptor inhibitor, A2BReceptor inhibitor, COX2 inhibitor, EP2 receptor antagonist, EP4receptor antagonist, RON kinase inhibitor, ALK5 kinase inhibitor, CSF1kinase inhibitor, PI3K delta kinase inhibitor, PI3K gamma kinaseinhibitor, BRAF V600E kinase inhibitor, arginase, and iNOS. IDO isindoleamine 2,3-dioxygenase, a key enzyme of tryptophan metabolism.

The immune modulating therapy may be radiotherapeutic immune stimulationchosen from gamma irradiation, external beam radiotherapy, stereotacticradiotherapy, radiosurgery, virtual simulation, 3-dimensional conformalradiation therapy, intensity-modulated radiation therapy,intensity-modulated radiation therapy (IMRT), volumetric modulated arctherapy (VMAT), particle therapy, proton beam therapy, auger therapy,brachytherapy, intraoperative radiotherapy, radioisotope therapy, andbeta irritation.

The immune modulating therapy may be a vaccine to TLR4 or TLR9. Thevaccine may be toll-like receptor 4 (TLR4). The vaccine may be toll-likereceptor 9 (TLR9).

The method may further comprise assessing whether a lymphatic system ina subject is dysregulated. Any method described herein may be used toassess the functioning of the lymphatic system.

C. Cancer

Certain tumor cell types as a group have consistently shown poorresponse to immune therapies in prospective clinical studies. Theseso-called “non-responder tumor types” include prostate, colon, breast,and other cancers. Even more, of those tumor cell types that have beenshown to respond, such as non-small cell lung cancer (NSCLC), melanoma,urothelial, renal cell, head and neck cancers, only small subsets ofpatients within these tumors classes have shown responses receiving truebenefit in overall survival (OS), while the remaining 75% or so do notrespond (the so-called “non-responder patients”). For example, in NSCLConly 25-30% receive strong benefit (the “responders”). Of the remaining75% “non-responder patients,” 10% have hyperprogession, who rapidlyprogress on immune therapy within 8 to 12 weeks. The remaining 50%derive no significant benefit beyond standard therapies.

Surprisingly, the present disclosure teaches these “non-responder tumortypes” and “non-responder patients” harbor high associations withlymphatic dysfunction (LD), such as lymphangitic carcinomatosis (LC).Moreover, LD and LC are stronger predictors of response than are PD-1 orPD-L1 status in patients with cancer treated with immune therapies, suchas checkpoint inhibitors. Contrary to the art, these therapies can beused to treat patients independent of PD-1/PD-L1 status. Further, inpatients with low PD-1/PD-L1 status that have been traditionally shownto not benefit from immune therapy, these patients do respond whenstratified by LD/LC status alone. Thus, the present disclosure providesthat by stratifying by LD alone as the single most influential factor orin combination with PD-1/PD-L1 status or other markers, (a) patientswith low PD-1/PD-L1 can be treated effectively with outcomes comparableto those with higher levels of PD-1/PD-L1 status, and (b) tumor typesthought to be resistant, even when stratified by high PD-1/L1, respondand benefit from these therapies.

The cancer may be chosen from lung cancer, breast cancer, a cancer ofthe gastrointestinal tract, a cancer of unknown origin, head and neckcancer, bladder cancer, prostate cancer, skin cancer, kidney cancer, aprimary brain tumor, ocular tumor, sarcoma, a cancer of primary softtissue, mesenchymal cancer, bone cancer, a tumor of the lymphaticsystem, and leukemia.

The cancer may be lung cancer chosen from non-small cell lung cancer(NSCLC), squamous cell lung cancer, large cell lung cancer, small celllung cancer, bronchogenic carcinoma, adenocarcinoma, neuroendocrine lungcancer, and bronchoalveolar lung cancer.

The cancer may be breast cancer chosen from ductal carcinoma in situ(DCIS), invasive ductal carcinoma (IDC), lobular carcinoma (ILC),inflammatory breast cancer, lobular carcinoma in situ (LCIS), malebreast cancer, Paget's disease of the nipple, and Phyllodes tumors ofthe breast. The breast cancer may be invasive ductal carcinoma chosenfrom tubular carcinoma of the breast, medullary carcinoma of the breast,mucinous carcinoma of the breast, papillary carcinoma of the breast, andcribriform carcinoma of the breast. The cancer may be breast cancerdefined by hormone receptor status chosen from estrogen receptorpositive, estrogen receptor negative, progesterone receptor positive,progesterone receptor negative, herceptin positive, herceptin negative,and combinations thereof. The cancer may be breast cancer defined byexpression of a predefined set of genes chosen from mammaprint,oncotypeDX, intrinsic subtypes, and nanostring prosigna.

The cancer may be a cancer of the gastrointestinal tract chosen from atumor of the stomach, gastric cancer, duodenal cancer, small or largeintestine cancer, colorectal cancer, anal cancer, liver cancer,pancreatic cancer, gall bladder cancer, cholangiocarcinoma, andneuroendocrine cancer.

The cancer may be a skin cancer chosen from basal cell cancer, squamouscell cancer, and melanoma.

The cancer may be kidney cancer chosen from renal cell cancer andoncocytoma.

The cancer may be a primary brain tumor, chosen from glioma, a tumorwith gliomatous components, a tumor with neuronal components, a tumorwith oligodendroglial components, oligodendroglioma, astrocytoma, andglioblastoma multiforme.

The cancer may be a tumor of the lymphatic system selected form thegroup consisting of B cell lymphoma, T cell lymphoma, diffuse B celllymphoma, and Hodgkin's lymphoma.

The cancer may be leukemia chosen from acute lymphoblastic leukemia,acute myeloid leukemia, chronic lymphocytic leukemia, and chronicmyelogenous leukemia.

The cancer may be lung cancer and the method further may compriseadministering one or more drugs chosen from afatinib dimaleate,alectinib, bevacizumab, carboplatin, ceritinib, crizotinib, docetaxel,doxorubicin, erlotinib, etoposide, everolimus, gefitinib, gemcitabine,mechlorethamine, methotrexate, necitumumab, nivolumab, osimertinib,paclitaxel, paclitaxel albumin-stabilized nanoparticles, pembrolizumab,pemetrexed, ramucirumab, topotecan, vinorelbine, pharmaceuticallyacceptable salts thereof, and combinations thereof.

The cancer may be advanced cancer or metastatic cancer.

D. Chemotherapeutic Agents

The methods described herein may be conducted in combination withadministering one or more chemotherapeutic agents. Non-limiting examplesof chemotherapeutic compounds which can be used in combinationtreatments include, for example, aminoglutethimide, amsacrine,anastrozole, asparaginase, BCG, bicalutamide, bleomycin, buserelin,busulfan, campothecin, capecitabine, carboplatin, carmustine,chlorambucil, cisplatin, cladribine, clodronate, colchicine,cyclophosphamide, cyproterone, cytarabine, dacarbazine, dactinomycin,daunorubicin, dienestrol, diethylstilbestrol, docetaxel, doxorubicin,epirubicin, estradiol, estramnustine, etoposide, exemestane, filgrastim,fludarabine, fludrocortisone, fluorouracil, fluoxymesterone, flutamide,gemcitabine, genistein, goserelin, hydroxyurea, idarubicin, ifosfamide,imatinib, interferon, irinotecan, ironotecan, letrozole, leucovorin,leuprolide, levamisole, lomustine, mechlorethamine, medroxyprogesterone,megestrol, melphalan, mercaptopurine, mesna, methotrexate, mitomycin,mitotane, mitoxantrone, nilutamide, nocodazole, octreotide, oxaliplatin,paclitaxel, pamidronate, pentostatin, plicamycin, porfimer,procarbazine, raltitrexed, rituximab, streptozocin, suramin, tamoxifen,temozolomide, teniposide, testosterone, thioguanine, thiotepa,titanocene dichloride, topotecan, trastuzumab, tretinoin, vinblastine,vincristine, vindesine, and vinorelbine.

These chemotherapeutic compounds may be categorized by their mechanismof action into, for example, following groups:anti-metabolites/anti-cancer agents, such as pyrimidine analogs(5-fluorouracil, floxuridine, capecitabine, gemcitabine and cytarabine)and purine analogs, folate antagonists and related inhibitors(mercaptopurine, thioguanine, pentostatin and 2-chlorodeoxyadenosine(cladribine)); antiproliferative/antimitotic agents including naturalproducts such as vinca alkaloids (vinblastine, vincristine, andvinorelbine), microtubule disruptors such as taxane (paclitaxel,docetaxel), vincristine, vinblastine, nocodazole, epothilones andnavelbine, epidipodophyllotoxins (etoposide, teniposide), DNA damagingagents (actinomycin, amsacrine, anthracyclines, bleomycin, busulfan,campothecin, carboplatin, chlorambucil, cisplatin, cyclophosphamide,cytoxan, dactinomycin, daunorubicin, doxorubicin, epirubicin,hexamethyhnelamineoxaliplatin, iphosphamide, melphalan,merchlorehtamine, mitomycin, mitoxantrone, nitrosourea, plicamycin,procarbazine, taxol, taxotere, teniposide, triethylenethiophosphoramideand etoposide (VP16)); antibiotics such as dactinomycin (actinomycin D),daunorubicin, doxorubicin (adriamycin), idarubicin, anthracyclines,mitoxantrone, bleomycins, plicamycin (mithramycin) and mitomycin;enzymes (L-asparaginase which systemically metabolizes L-asparagine anddeprives cells which do not have the capacity to synthesize their ownasparagine); antiplatelet agents; antiproliferative/antimitoticalkylating agents such as nitrogen mustards (mechlorethamine,cyclophosphamide and analogs, melphalan, chlorambucil), ethyleniminesand methylmelamines (hexamethylmelamine and thiotepa), alkylsulfonates-busulfan, nitrosoureas (carmustine (BCNU) and analogs,streptozocin), trazenes-dacarbazinine (DTIC);antiproliferative/antimitotic antimetabolites such as folic acid analogs(methotrexate); platinum coordination complexes (cisplatin,carboplatin), procarbazine, hydroxyurea, mitotane, aminoglutethimide;hormones, hormone analogs (estrogen, tamoxifen, goserelin, bicalutamide,nilutamide) and aromatase inhibitors (letrozole, anastrozole);anticoagulants (heparin, synthetic heparin salts and other inhibitors ofthrombin); fibrinolytic agents (such as tissue plasminogen activator,streptokinase and urokinase), aspirin, dipyridamole, ticlopidine,clopidogrel, abcizimab; antimigratory agents; antisecretory agents(breveldin); immunosuppressives (cyclosporine, tacrolimus (FK-506),sirolimus (rapamycin), azathioprine, mycophenolate mofetil);antiangiogenic compounds (e.g., TNP-470, genistein, bevacizumab) andgrowth factor inhibitors (e.g., fibroblast growth factor (FGF)inhibitors); angiotensin receptor blocker; nitric oxide donors;anti-sense oligonucleotides; antibodies (trastuzumab); cell cycleinhibitors and differentiation inducers (tretinoin); mTOR inhibitors,topoisomerase inhibitors (doxorubicin (adriamycin), amsacrine,campothecin, daunorubicin, dactinomycin, eniposide, epirubicin,etoposide, idarubicin and mitoxantrone, topotecan, irinotecan),corticosteroids (cortisone, dexamethasone, hydrocortisone,methylprednisolone, prednisone, and prednisolone); growth factor signaltransduction kinase inhibitors; mitochondrial dysfunction inducers andcaspase activators; and chromatin disruptors.

The cancer may be lung cancer, such as non-small cell lung cancer(NSCLC). Suitable drugs for treated non-small cell lung cancer include,but are not limited to, Abitrexate™ (methotrexate), Abraxane™(paclitaxel albumin-stabilized nanoparticles), Afinitor™ (everolimus),Alecensa™ (alectinib), Alimta™ (pemetrexed disodium), Avastin™(bevacizumab), Cyramza™ (ramucirumab), Folex™ (methotrexate), GilotriflM(afatinib dimaleate), Gemzar™ (gemcitabine hydrochloride), Iressa™(gefitinib), Keytruda™ (pembrolizumab), Mexate™ (methotrexate),Mustargen™ (mechlorethamine hydrochloride), Navelbine™ (vinorelbinetartrate), Opdivo™ (nivolumab), Paraplat™ (carboplatin), Paraplatin™(carboplatin), Portrazza™ (necitumumab), Tagrisso™, (osimertinib),Tarceva™ (erlotinib hydrochloride), Taxol™ (paclitaxel), Taxotere™(docetaxel), Xalkori™ (crizotinib), and Zykadia™ (ceritinib). Suitabledrug combinations for treating non-small cell lung cancer include, butare not limited to, carboplatin and taxol, and gemcitabine andcisplatin.

Suitable drugs for treating small cell lung cancer include, but are notlimited to, Abitrexate™ (methotrexate), Afinitor™ (everolimus),doxorubicin hydrochloride, Etopophos™ (etoposide phosphate), etoposide,Folex™ (methotrexate), Hycamtin™ (topotecan hydrochloride), Mexate™(methotrexate), and Mustargen™ mechlorethamine hydrochloride).

Pharmaceutical compounds that can be used in combination with a VEGFR-3and a cancer immune modulating therapy such as an immune checkpointinhibitor and (0) VEGFR-2 antagonist: (1) inhibitors of release of“angiogenic molecules,” such as bfGF (basic fibroblast growth factor);(2) neutralizers of angiogenic molecules, such as an anti-ObHGFantibodies; and (3) inhibitors of endothelial cell response toangiogenic stimuli, including collagenase inhibitor, basement membraneturnover inhibitors, angiostatic steroids, fungal-derived angiogenesisinhibitors, platelet factor 4, thrombospondin, arthritis drugs such asD-penicillamine and gold thiomalate, vitamin D3 analogs, alphainterferon, and the like.

E. Angiogenesis Inhibitors

The methods described herein may be conducted in combination withadministering one or more angiogenesis inhibitors. Compounds thatinhibit angiogenesis include for example endostatin protein orderivatives, lysine binding fragments of angiostatin, melanin ormelanin-promoting compounds, plasminogen fragments (e.g., Kringles 1-3of plasminogen), tropoin subunits, antagonists of vitronectin, peptidesderived from Saposin B, antibiotics or analogs (e.g., tetracycline, orneomycin), dienogest-containing compositions, compounds comprising aMetAP-2 inhibitory core coupled to a peptide, the com pound EM-138,chalcone and its analogs, and naaladase inhibitors.

Depending on the combinatory therapy, administration of the polypeptidetherapeutic agents may be continued while the other therapy isadministered and/or thereafter. Administration of the therapeutic agentscan be made in a single dose, or in multiple doses. In some instances,administration of the therapeutic agents can begin at least several daysbefore the conventional therapy, while in other instances,administration can begin either immediately before or at the time ofadministering the conventional therapy.

Although the disclosure described herein is susceptible to variousmodifications and alternative iterations, specific embodiments thereofhave been described in greater detail above. It should be understood,however, that the detailed description of the composition is notintended to limit the disclosure to the specific embodiments disclosed.Rather, the disclosure is intended to cover all modifications,equivalents, and alternatives falling within the spirit and scope of thedisclosure as defined by the claim language.

Definitions

The compounds described herein have asymmetric centers. Compounds of thepresent disclosure having an asymmetrically substituted atom may beisolated in optically active or racemic form. All chiral,diastereomeric, racemic forms and all geometric isomeric forms of astructure are intended, unless the specific stereochemistry or isomericform is specifically indicated.

“Inhibiting an established tumor metastasis” refers to decreasing thesize and/or rate of growth of a metastasis which has been alreadyestablished. Established metastases include metastases in lymph nodes(regional metastases) and distant organs (systemic metastases).

“Lymphangiogenesis” refers to growth of new lymphatic vessels.

“Therapeutically effective” applied to dose or amount refers to thatquantity of a pharmaceutical composition sufficient to result in adesired therapeutic activity upon administration to a subject in needthereof, or sufficient to reduce or eliminate at least one symptom ofthe disease being treated.

“Subject” means any animal, including mammals. The term may refer to ahuman, a non-human primate, a bovine, an ovine, an equine, a porcine, acanine, a feline, or a rodent (mouse or rat).

When introducing elements of the present disclosure or theembodiments(s) thereof, the articles “a,” “an,” “the,” and “said” areintended to mean that there are one or more of the elements. The terms“comprising,” “including,” and “having” are intended to be inclusive andmean that there may be other elements other than the listed elements.

Having described the disclosure in detail, it will be apparent thatmodifications and variations are possible without departing from thescope of the disclosure defined in the appended claims.

Examples

The following examples are included to show certain embodiments of thedisclosure. It should be appreciated by those of skill in the art thatthe techniques disclosed in the examples represent techniques discoveredby the inventors to function well in the practice of the disclosure.Those of skill in the art should, however, considering the presentdisclosure, appreciate that many changes can be made in the specificembodiments disclosed and still obtain a like or similar result withoutdeparting from the spirit and scope of the disclosure, therefore allmatter set forth is to be interpreted as illustrative and not in alimiting sense.

Tumors responded to checkpoint inhibition based upon lymphaticdysfunction, independent of PD-1/L1, DNA mismatch repair status,microsatellite instability status, or hypermutant status/tumorneoantigen burden.

Patients with advanced or metastatic lung cancer were treated with aninhibitor of PD-1. Patients with a low or negative PD-L1 tumorproportion score (TPS) were evaluated as specified by the drug label,and thus not indicated for the drug and not expected to respond. Theirlymphatic systems were evaluated for the dysfunction. In one instance,lymphatic system evaluation was performed with serum measurements ofVEGF C, VEGF D or heparin-binding factor midkine in patients beforetherapy or during treatment. In other instances, the dysfunction wasmeasured with pre-treatment imaging studies and/or similar imagingacross treatment with immunotherapy therapy, including computedtomography, MRI, and nuclear medicine tests including PET imaging orventilation perfusion scan.

Evaluating objective measures of response in these patients based onprogression free survival, overall survival and durable and objectiveresponse (RECIST 1.1) and by immune-related response criteria (irRC)confirmed that patients with dysregulated lymphatic systems (designatedas “Biomarker Positive” groups) did significantly worse across all theseobjective measures (overall survival, progression free survival,objective response, and durable clinical response).

Keytruda™ product label teaches to the contrary. Pembrolizumab (formerlyMK-3475 and lambrolizumab, trade name Keytruda™) is a humanized antibodyused in cancer immunotherapy. It blocks a protective mechanism on cancercells, and allows the immune system to destroy those cancer cells. Ittargets the programmed cell death 1 (PD-1) receptor. It is indicated forpatients with metastatic NSCLC, whose tumors have high PD-L1 expressionwith a tumor proportion score (TPS) of at least 50%, as determined by anFDA-approved test, with no epidermal growth factor receptor (EGFR) oranaplastic lymphoma kinase (ALK). Keytruda™ is also indicated forpatients with metastatic NSCLC, whose tumors express PD-L1 (TPS of atleast 1%), as determined by an FDA-approved test, with disease progresson or after platinum-containing chemotherapy. That is, the art teachesthat patients with low PD-L1 levels cannot be treated.

Opdivo™ is a programmed death receptor-1 (PD-1) blocking antibody. Alsoknown as, nivolumab is indicated for adult and pediatric (12 years andolder) patients with microsatellite instability-high (MSI-H) or mismatchrepair deficient (dMMR) metastatic colorectal cancer that has progressedfollowing treatment with a fluoropyrimidine, oxaliplatin, andirinotecan. Again, the art teaches that patients with low PD-L1 levelscannot be treated.

However, contrary to teaching in the art, patients without adysregulated lymphatic system, yet who were not expected to respondbased on their PD-L1 TPS, had a striking response to the therapy withsignificant duration of overall and progression free survival, thusconfirming that the lymphatic system critically determined response toimmune checkpoint therapy.

Further, statistical analysis showed that the presence of a dysregulatedlymphatic system in this cohort was the single strongest factor forpredicting response, outweighing other known important prognostic andpredictive factors including age, race, immunotherapy dosing, totaltumor burden, gender, smoking and mutation status, and lung cancer celltype. Similar results were seen in patients with treated with PD-L1inhibitors, with low neoantigen burdens, hypermutant status, and thetumor types shown not to respond to checkpoint inhibition therapydescribed above.

FIG. 8 is a Kaplan Meier plot of Overall Survival (OS) in the subset ofNSCLC patients with PD-L1− staining (TPS<1%) showing that patientsLC−/PD-L1− derive a significant benefit from the checkpoint inhibitorpembrolizumab compared to the small subset of patients LC+/PD-L1−(p<0.05) independent of PD-L1 status/TPS scoring.

FIG. 9 is a Kaplan Meier plot of progression free survival (PFS) in thesubset of NSCLC patients with negative PD-L1 staining (TPS<1%) like FIG.8. showing that patients LC−/PD-L1− derive a significant PFS benefitfrom the checkpoint inhibitor pembrolizumab compared to the small subsetof patients that LC+/PD-L1− (p<0.05). Thus, even in patients that theart (drug label at FIG. 4) teaches will not respond to checkpointinhibition (low or no PD-L1 staining), derive significant clinicalbenefits in PFS independent of PD-L1 status, as deemed by the morepowerful and independent LC status.

Thus, dysregulated lymphatic systems were a powerful predictor ofresponse to immune-modulating therapies independent of the art whichteaches that PD-L1/PD-1 TPS and hypermutant/neoantigen status werecritical determinants of response. Certain tumors types, such as triplenegative breast cancer, colon, pancreatic, glioblastoma multiforme(GBM), prostate cancer, inflammatory, and ER+/HER2+ breast cancers, didnot respond well to these therapies.

While specific embodiments have been described above regarding thedisclosed embodiments and examples, such embodiments are onlyillustrative and do not limit the scope of the disclosure. Changes andmodifications can be made following ordinary skill in the art withoutdeparting from the disclosure in its broader aspects as defined in thefollowing claims.

What is claimed is:
 1. A method for treating cancer in a patient in needthereof, wherein said cancer has a tumor proportion score (TPS) forprogrammed death receptor-1 (PD-1) or programmed death-ligand-1 (PD-L1)of 50% or less and said patient is negative for lymphatic dysfunction,comprising administering a therapeutically effective amount of anantagonist for immune checkpoint inhibition.
 2. The method of claim 1,wherein the TPS is 30% or less.
 3. The method of claim 2, wherein theTPS is 10% or less.
 4. The method of any of claims 1 to 3, wherein thelymphatic dysfunction is lymphangitic carcinomatosis (LC).
 5. The methodof any of claims 1 to 4, wherein the immune checkpoint inhibition has atarget chosen from PD-1, PD-L1, CTLA-4, LAG3, TIM-2, CD47, KIR, TIM3,CD30, OX40, IDO, and ICOS.
 6. The method of claim 5, wherein the immunecheckpoint inhibition targets PD-1 or PD-L1.
 7. The method of any ofclaims 1 to 6, wherein the antagonist is chosen from afatinib dimaleate,alectinib, bevacizumab, carboplatin, ceritinib, crizotinib, docetaxel,doxorubicin, erlotinib, etoposide, everolimus, gefitinib, gemcitabine,mechlorethamine, methotrexate, necitumumab, nivolumab, osimertinib,paclitaxel, paclitaxel albumin-stabilized nanoparticles, pembrolizumab,pemetrexed, ramucirumab, topotecan, vinorelbine, pharmaceuticallyacceptable salts thereof, and combinations thereof.
 8. The method ofclaim 7, wherein the antagonist is chosen from bevacizumab, necitumumab,nivolumab, pembrolizumab, ramucirumab, pharmaceutically acceptable saltsthereof, and combinations thereof.
 9. The method of claim 8, wherein theantagonist is pembrolizumab or pharmaceutically acceptable saltsthereof.
 10. The method of any of claims 1 to 9, wherein the cancer ischosen from lung cancer, breast cancer, a cancer of the gastrointestinaltract, a cancer of unknown origin, head and neck cancer, bladder cancer,prostate cancer, skin cancer, kidney cancer, a primary brain tumor,ocular tumor, sarcoma, a cancer of primary soft tissue, mesenchymalcancer, bone cancer, ovarian cancer, cervical cancer, a tumor of thelymphatic system, leukemia, mismatch repair deficient positive tumors(MMRD positive), mismatch repair deficient negative tumors (MMRDnegative), and microsatellite (MSI) instability positive or negativecancers.
 11. The method of claim 10, wherein the cancer is lung cancerchosen from non-small cell lung cancer (NSCLC), squamous cell lungcancer, large cell lung cancer, small cell lung cancer, bronchogeniccarcinoma, adenocarcinoma, neuroendocrine lung cancer, andbronchoalveolar lung cancer.
 12. The method of claim 11, wherein thecancer is breast cancer chosen from ductal carcinoma in situ (DCIS),invasive ductal carcinoma (IDC), lobular carcinoma (ILC), inflammatorybreast cancer, lobular carcinoma in situ (LCIS), male breast cancer,Paget's disease of the nipple, and Phyllodes tumors of the breast. 13.The method of claim 10, wherein the breast cancer is invasive ductalcarcinoma chosen from tubular carcinoma of the breast, medullarycarcinoma of the breast, mucinous carcinoma of the breast, papillarycarcinoma of the breast, and cribriform carcinoma of the breast.
 14. Themethod of claim 13, wherein the cancer is breast cancer defined byhormone receptor status chosen from estrogen receptor positive, estrogenreceptor negative, progesterone receptor positive, progesterone receptornegative, herceptin positive, herceptin negative, and combinationsthereof.
 15. The method of claim 13, wherein the cancer is breast cancerdefined by expression of a pre-defined set of genes chosen frommammaprint, oncotypeDX, intrinsic subtypes, and nanostring prosigna. 16.The method of claim 10, wherein the cancer is a cancer of thegastrointestinal tract chosen from a tumor of the stomach, gastriccancer, duodenal cancer, small or large intestine cancer, colorectalcancer, anal cancer, liver cancer, pancreatic cancer, gall bladdercancer, cholangiocarcinoma, and neuroendocrine cancer.
 17. The method ofclaim 10, wherein the cancer is a skin cancer chosen from basal cellcancer, squamous cell cancer, and melanoma.
 18. The method of claim 10,wherein the cancer is kidney cancer chosen from renal cell cancer,papillary, and oncocytoma.
 19. The method of claim 10, wherein thecancer is a primary brain tumor, chosen from glioma, a tumor withgliomatous components, a tumor with neuronal components, a tumor witholigodendroglial components, oligodendroglioma, astrocytoma, andglioblastoma multiforme.
 20. The method of claim 10, wherein the canceris a tumor of the lymphatic system selected form the group consisting ofB cell lymphoma, T cell lymphoma, diffuse B cell lymphoma, and Hodgkin'slymphoma.
 21. The method of claim 10, wherein the cancer is leukemiachosen from acute lymphoblastic leukemia, acute myeloid leukemia,chronic lymphocytic leukemia, and chronic myelogenous leukemia.
 22. Themethod of any of claims 1 to 10, wherein the cancer is lung cancer andthe antagonist is chosen from afatinib dimaleate, alectinib,bevacizumab, carboplatin, ceritinib, crizotinib, docetaxel, doxorubicin,erlotinib, etoposide, everolimus, gefitinib, gemcitabine,mechlorethamine, methotrexate, necitumumab, nivolumab, osimertinib,paclitaxel, paclitaxel albumin-stabilized nanoparticles, pembrolizumab,pemetrexed, ramucirumab, topotecan, vinorelbine, pharmaceuticallyacceptable salts thereof, and combinations thereof.
 23. The method ofany of claims 1 to 22, wherein the cancer is advanced cancer ormetastatic cancer.
 24. A method for treating lung cancer in a patient inneed thereof, which cancer has a tumor proportion score for programmeddeath receptor-1 (PD-1) or programmed death-ligand-1 (PD-L1) of 30% orless and said patient is negative for lymphangitic carcinomatosis (LC),comprising administering a therapeutically effective amount of anantagonist for immune checkpoint inhibition targeting PD-1 or PD-L1. 25.The method of claim 22, wherein the antagonist is chosen frombevacizumab, necitumumab, nivolumab, pembrolizumab, ramucirumab,pharmaceutically acceptable salts thereof, and combinations thereof. 26.The method of claim 23, wherein the antagonist is pembrolizumab orpharmaceutically acceptable salts thereof.
 27. The method of any ofclaims 22 to 24, wherein the lung cancer is chosen from non-small celllung cancer (NSCLC), squamous cell lung cancer, large cell lung cancer,small cell lung cancer, bronchogenic carcinoma, adenocarcinoma,neuroendocrine lung cancer, and bronchoalveolar lung cancer.
 28. Themethod of any of claims 22 to 25, wherein the lung cancer is advancedcancer or metastatic cancer.
 29. A method for treating lung cancer in apatient in need thereof, which cancer has a tumor proportion score forprogrammed death receptor-1 (PD-1) or programmed death-ligand-1 (PD-L1)of 30% or less and said patient is negative for lymphangiticcarcinomatosis (LC), comprising administering a therapeuticallyeffective amount of pembrolizumab or a pharmaceutically acceptable saltthereof.
 30. The method of claim 27, wherein the cancer is lung cancerchosen from non-small cell lung cancer (NSCLC), squamous cell lungcancer, large cell lung cancer, small cell lung cancer, bronchogeniccarcinoma, adenocarcinoma, neuroendocrine lung cancer, andbronchoalveolar lung cancer.
 31. A method for treating cancer in apatient in need thereof, by determining if said cancer has a tumorproportion score for programmed death receptor-1 (PD-1) or programmeddeath-ligand-1 (PD-L1) of 30% or less and confirming said patient isnegative for lymphatic dysfunction, then administering a therapeuticallyeffective amount of an antagonist for immune checkpoint inhibition. 32.A method for treating cancer in a patient in need thereof, wherein saidcancer has a tumor proportion score for programmed death receptor-1(PD-1) or programmed death-ligand-1 (PD-L1) of 30% or less byadministering a therapeutically effective amount of an antagonist forimmune checkpoint inhibition.
 33. The method of claim 30, wherein theantagonist is pembrolizumab.